Woodlands Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. The last rating for this key question was good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of a legal regulation relating to good governance.

The provider was in breach of legal regulations because they had failed to comply with the conditions of their registration.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider’s vision and strategy for the service did not align with their legal responsibilities or keeping people safe. They had not always identified or planned for risks. The provider had placed people in unsafe situations whilst they were undertaking building work at the service. Despite not having enough bedrooms to accommodate people safely, they had admitted new people and people returning from hospital to the home. This was not in people’s best interests. They had not kept the commissioning authorities, CQC or the host local authority updated with the situation or the impact this had on people living at the home.

The registered manager had consulted with CQC regarding the registration of a new location to accommodate people whilst building works were taking place. They were informed of their legal responsibilities but did not follow these.

The provider and registered manager had failed to ensure legal regulations were being followed. We identified serious breaches of regulations which placed people at risk of harm. Therefore, leaders were not able to demonstrate consistent knowledge about their legal responsibilities or providing a safe and good quality service.

Whilst we identified concerns about the quality and safety of the service, people living there and their relatives told us they found the management team supportive and helpful. Their comments included, “[Deputy manager] goes out of [their] way to get what’s needed” and “[Registered manager] is the owner and is just lovely. [Deputy manager] is a wonderful manager. I am so impressed [they know] each resident well.” Staff told us they thought the management team were supportive and available when they needed them.

The provider had systems for speaking up and staff were familiar with these. Staff told us they knew what to do if they had concerns and felt confident speaking up. However, staff had not identified people were being placed at risk from unsafe practice. They had not spoken up or raised concerns outside of the company. People living at Woodlands Care Home did not have the mental capacity to speak up for themselves and relied on staff to speak up about abuse and breaches of their human rights.

The provider had procedures to help ensure the workforce were fairly treated and there was no discrimination. Staff told us they felt supported with requests for working hours and with their individual needs.

The provider’s governance systems had not been effective. We found they had breached conditions of their registration and were providing accommodation and personal care to people from a location other than Woodlands Care Home. They had moved 6 people into a different location during refurbishment of the home. The building was not suitable, and people were not being safely cared for.

The provider’s systems had not effectively assessed or mitigated risks. We identified concerns relating to safe staffing levels, fire safety, and the safety of the environment. The provider’ systems had failed to identify these. We judged people were at extreme risk of harm and took action to impose conditions on the provider’ registration. Following this we were satisfied that immediate risks were removed. The provider had not identified or taken action to mitigate these risks before we told them to.

We had identified further concerns relating to medicines management, infection prevention and control, risk assessment, safeguarding people from improper treatment, care plan records and treating people with dignity and respect. The provider had not effectively identified issues or taken enough action to remedy these.

In addition to the action we have already taken, we have told the provider they must keep us updated with further action they take to reduce risks and to monitor the quality and safety of the service.

The provider had not worked in partnership and collaboration. They had not consulted partners and commissioners when they changed the care provision. This meant they had made unlawful decisions and actions that had placed people at risk of significant harm without other care professionals knowing about this. The provider had not been open and transparent with commissioners or CQC.

The provider worked with healthcare professionals in the local community to monitor people’s needs. The provider managed a local day centre. People from both the care home and day centre sometimes spent time together sharing activities.

The provider’s systems for learning and innovation had not identified serious risk and inappropriate care. Changes at the service meant people were not safe and did not receive good quality of experience. The systems for learning had not been well embedded because staff and leaders had not understood their legal responsibilities or identified unlawful practice.